Norfolk Health Overview and Scrutiny Committee Date: Thursday 25 November 2010 Time: 10.00Am Venue: Edwards Room, County Hall, Norwich

Norfolk Health Overview and Scrutiny Committee Date: Thursday 25 November 2010 Time: 10.00am Venue: Edwards Room, County Hall, Norwich

Persons attending the meeting are requested to turn off mobile phones.

Members of the public or interested parties who have indicated before the meeting that they wish to speak will, at the discretion of the Chairman, be given five minutes at the microphone. Others may ask to speak and this again is at the discretion of the Chairman. Membership MAIN MEMBER SUBSTITUTE MEMBER REPRESENTING Mr J Bracey Mr P Balcombe Broadland District Council Mr D Bradford Mr A Wiltshire Norwich City Council Mr M Carttiss Mr G Cook / Mr T Garrod / Ms Norfolk County Council D Irving Mrs J Chamberlin Mr G Cook / Mr T Garrod / Ms Norfolk County Council D Irving Michael Chenery of Mr G Cook / Mr T Garrod / Ms Norfolk County Council Horsburgh D Irving Mr S Dorrington Mr G Cook / Mr T Garrod / Ms Norfolk County Council D Irving Mr R Bearman Mr S Little Norfolk County Council Mr D Harrison Mr J Joyce Norfolk County Council Mr J Labouchere Mr R Kybird Breckland District Council Dr N Legg Mrs C Stevens South Norfolk District Council Mrs B A McGoun Mr N D Dixon North Norfolk District Council Mr J Perry-Warnes Mr G Cook / Mr T Garrod / Ms Norfolk County Council D Irving Mr G Sandell Mr C Walters King’s Lynn and West Norfolk Borough Council Mrs S Weymouth Mrs P E Page Great Yarmouth Borough Council Mr A J Wright Mr G Cook / Mr T Garrod / Ms Norfolk County Council D Irving For further details and general enquiries about this Agenda please contact the Committee Administrator: Tim Shaw on 01603 222948 or email [email protected]

-1- Norfolk Health Overview and Scrutiny Committee – 25 November 2010

1. To receive apologies and details of any substitute members attending

2. Glossary of Terms and Abbreviations

Terms and abbreviations used in the agenda papers. (Page )

3. Minutes

To confirm the minutes of the meeting of the Norfolk (Page ) Health Overview and Scrutiny Committee held on 14 October 2010.

4. Members to Declare any Interests

Please indicate whether the interest is a personal one only or one which is prejudicial. A declaration of a personal interest should indicate the nature of the interest and the agenda item to which it relates. In the case of a personal interest, the member may speak and vote on the matter. Please note that if you are exempt from declaring a personal interest because it arises solely from your position on a body to which you were nominated by the County Council or a body exercising functions of a public nature (e.g. another local authority), you need only declare your interest if and when you intend to speak on a matter.

If a prejudicial interest is declared, the member should withdraw from the room whilst the matter is discussed unless members of the public are allowed to make representations, give evidence or answer questions about the matter, in which case you may attend the meeting for that purpose. You must immediately leave the room when you have finished or the meeting decides you have finished, if earlier. These declarations apply to all those members present, whether the member is part of the meeting, attending to speak as a local member on an item or simply observing the meeting from the public seating area.

5. To receive any items of business which the Chairman decides should be considered as a matter of urgency

6. Chairman’s announcements

7. 10:10– Norfolk and Waveney Mental Health NHS Foundation 10:50 Trust and Suffolk Mental Health Partnership – Potential Merger

2 Norfolk Health Overview and Scrutiny Committee – 25 November 2010

An information report from the Director of Finance and (Page ) Deputy Chief Executive of Norfolk and Waveney Mental Health NHS Foundation Trust.

8. 10:50 – Provision of Primary Care at Terrington St John 11:10 A briefing from NHS Norfolk on the arrangements for (Page ) provision of primary care from temporary buildings.

11:10 – Break at the Chairman’s discretion 11:20

9. 11:20 – Hospital Discharge Processes 12:00 An update from Norfolk Local Involvement Network on its (Page ) work on acute hospital discharge processes.

10. 12:00 – Norfolk Community Health and Care 12:40 A presentation by the Chairman and Chief Executive of (Page ) Norfolk Community Health and Care on the implications of attaining independent Trust status and moving towards Community Foundation Trust Status.

11. 12:40 – Forward Work Programme 12:50 To consider and agree the forward work programme. (Page )

Chris Walton Head of Democratic Services

County Hall Martineau Lane Norwich NR1 2DH

Date Agenda Published: 17 November 2010

Main Committee Members have a formal link with the following local NHS Trusts:

 Mr Wright – NHS Norfolk (PCT)  Mr Sandell and Mr Wright – Queen Elizabeth Hospital, King’s Lynn NHS Trust  Mr J Bracey – Norfolk and Waveney Mental Health NHS Foundation Trust.

3 Norfolk Health Overview and Scrutiny Committee – 25 November 2010

 Mrs S Weymouth – NHS Great Yarmouth and Waveney (PCT).  Dr N Legg – Norfolk and Norwich University Hospital NHS Foundation Trust  Mr M Carttiss and Mrs S Weymouth – James Paget University Hospital NHS Foundation Trust

NORFOLK HEALTH OVERVIEW AND SCRUTINY COMMITTEE PROGRAMME OF FUTURE MEETINGS

20 January 2011 14 April 2011 3 March 2011 26 May 2011

If you need this Agenda in large print, audio, Braille, alternative format or in a different language please contact Tim Shaw on 0344 800 8020 or Textphone 0344 800 8011 and we will do our best to help.

NORFOLK HEALTH OVERVIEW AND SCRUTINY COMMITTEE MINUTES OF THE MEETING HELD ON 14 OCTOBER 2010

Present:

Mr M R H Carttiss (Chairman) Chairman, Norfolk County Council Mr R Bearman Norfolk County Council Mr J Bracey Broadland District Council Mrs J Chamberlin Norfolk County Council Michael Chenery of Horsbrugh Norfolk County Council Mr S Dorrington Norfolk County Council Mr D Harrison Norfolk County Council Mr G Sandell King’s Lynn and West Norfolk Borough Council Mrs S Weymouth Great Yarmouth Borough Council Mr A J Wright Norfolk County Council

Substitute Member Present:

Mr R Kybird for Mr J Labouchere, Breckland District Council

Also Present:

Dr Penny Morgan Clinical Lead, Asperger Service Norfolk, Norfolk Learning Difficulties Services Steve McCormack Programme Manager, Mental Health and Learning Disabilities, NHS Norfolk Catherine Underwood Community Services, Norfolk County Council Steve Bloomfield Head of Adult Services, Asperger East Anglia Anne Ebbage Autism Anglia David Stonehouse Deputy Chief Executive and Director of Finance, NHS Norfolk Peter Balcombe Broadland District Council Anthony Darwood Norfolk LINk Eileen Ryan Parent Natalie Williams NHS Great Yarmouth and Waveney Patrick Thompson Norfolk LINk David Sparkes Norfolk LINk Maureen Orr Scrutiny Support Manager (Health) Chris Walton Head of Democratic Services Tim Shaw Committee Officer

1 Apologies

Apologies for absence were received from Mr D Bradford, Mr J Labouchere, Dr N Legg, Mrs B A McGoun and Mr J Perry-Warnes

2 Glossary of Terms and Abbreviations

Members received a glossary of the terms and abbreviations used in the agenda papers. - 1 -

3 Minutes

The minutes of the previous meeting held 2 September 2010 were confirmed by the Committee and signed by the Chairman subject to the addition of Dr P Thompson being added to the list of those present.

4 Declarations of Interest

Mr G Sandell declared a personal interest in the item about health provision for adults with autism because he undertook part-time work for adults with learning difficulties, including those with autism.

5 Urgent Business

There were no items of urgent business.

6 Chairman’s Announcements

The Chairman reminded Members that the meeting would be followed that afternoon by a visit to the Norfolk and Norwich Hospital, and he explained the arrangements that had been made.

7 Health Provision for Adults with Autism

The Committee received a suggested approach from Maureen Orr, Scrutiny Support Manager (Health), to a report from NHS Norfolk on the services it commissioned in light of the Autism Act 2009 and the national strategy for adults with autism “Fulfilling and Rewarding Lives”.

The Committee received evidence from the following witnesses:

Steve McCormack – Programme Manager, Mental Health and Learning Disabilities, NHS Norfolk Dr Penny Morgan – Clinical Lead, Asperger Service Norfolk, Norfolk Learning Difficulties Services Catherine Underwood – Director of Commissioning, Community Health and Care, Norfolk County Council Community Services Steve Bloomfield – Head of Adult Services, Asperger East Anglia Anne Ebbage – Autism Anglia

The Committee noted that Asperger East Anglia and Autism Anglia provided a “patient voice”, and were also organisations that provided services, holding contracts with Community Services, Norfolk County Council.

In hearing from the witnesses and in answer to Members questions, the Committee noted the following:

 The Autism Act had come into force in November 2009.  Norfolk was ahead of the national average for health provision for adults with autism  Those with learning difficulties did not always get the assistance that they needed for autism - 2 -  The knowledge and understanding of autism among GP’s varied greatly across practices  There were checklists for the use of GPs who were considering referring a patient suspected of having autism. Those adults with autism who had an accompanying learning difficulty or mental health problem were diagnosed by consultant clinical psychiatrists and consultant psychologists.  The health records of those with autism would be expanded in future so that they could be referred to when necessary to inform case decisions or support applications for additional services.  Working with all interested parties, the Asperger Service Norfolk had set up a steering group that had developed protocols for the service.  In January 2010 a trial programme was set up between Asperger East Anglia, Norfolk County Council and NHS Norfolk.  Following a successful trial, the initial contract had been placed with Asperger East Anglia.  Since 1 January 2010 (and as at mid-July 2010) there were:

61 referrals for diagnosis 6 referrals for careplan/support 34 parents and carers supported

 The Asperger Service Norfolk worked with but did not replace existing services  The staffing of the Asperger Service was as follows:

Asperger Service Norfolk – 3 support workers 0.5 clinical psychologists (to be increased) 1 level two social worker

Norfolk Learning Difficulties Service – Lead Psychologist Diagnostic support for psychologists in service

 Members were of the view that the current pathways to the diagnosis of autism for adults were not well understood by the general public. In developing the commissioning plan around services for adults with autism, accurate information was required to be put in it about the number and profile of people with autism in Norfolk.  The diagnostic pathway for children needed to be looked at separately to that for adults. It was recognised that this was outside the remit of this agenda item, and would need to be the subject of a separate report to the Committee.  The views of adults with autism and their carers needed to be taken more into account in the development of services for these people.  The witnesses from NHS Norfolk, the Norfolk Learning Difficulties Services and Community Services assured the Committee that in developing their plans, the County Council and the NHS were giving careful consideration to the role of organisations such as Asperger East Anglia and Autism Anglia to meet the needs of adults with these conditions.  Some health and social care professionals required detailed training on autism awareness, and this was currently available in London but not in Norfolk. - 3 -  Adults with autism needed to be able to access appropriate employment advice, making it easier for them to obtain work.  Employers were not always able to identify potential signs of autism. For some adults, working at night in a supermarket, where they did not have much social contact with others, might be an appropriate form of employment.  Autism Anglia worked with both adults and children.  Autism Anglia was a registered Charity that produced its own newsletters and leaflets for those with an interest in autism.  Autism Anglia welcomed the development of Asperger Service Norfolk, which they saw as a positive step towards diagnostic provision and specialist support services for adults with Asperger Syndrome. It was, however, pointed out that the autistic spectrum was wide and for many adults there remained difficulties in accessing the right services, including diagnosis.  Adults that fell in the grey area between learning difficulties and mental health services received less of a service despite the fact that they actually had the most complex needs.  It was of some concern to Autism Anglia that statutory bodies were referring increasing numbers of cases to it, without providing it with appropriate funding to take on more cases.  Asperger East Anglia was a partner in the Asperger Service Norfolk with the NHS and the County Council. Asperger East Anglia provided advice, information, support and training to those with Asperger Syndrome.  Increasing numbers of adults who were having difficulties relating to work colleagues were being referred to Asperger East Anglia.  Increasing numbers of adults were also being referred to Asperger East Anglia by Relate.  Asperger East Anglia had undertaken some joint work with the police.  More joint working was needed with the Prison Service.

Patrick Thompson, Norfolk LINk, spoke about the need for joint working with the Prison Service. He also said that he was concerned that the voluntary sector was being asked to provide services to those with autism, when such services could be provided at a higher level by statutory bodies. In reply, Steve McCormack said that the Joint Commissioners were looking into the reasons why people ended up in prison and the links to autism.

The Committee noted:

 The information about the national consultation “Fulfilling Rewarding Lives”.  The progress which had been made and the additional plans being prepared to further develop a Norfolk Joint Commissioning Strategy for People with Autism with full stakeholder engagement.  The progress which had been made with stakeholder engagement in developing and delivering the Asperger Service Norfolk and its levels of performance already achieved.  Members might want to give further consideration to this topic sometime in the new year.

Note: At the end of the meeting the Committee agreed to add the subject of - 4 - children’s autism services to their forward work programme for March 2011. Members wanted to know what the diagnostic pathway for children was, and to receive information to show that there were no undue delays in the diagnosis of children.

8 Proposed Merger of Mental Health Trusts in Norfolk and Suffolk

The Committee received a report by the Scrutiny Support Manager (Health) that asked Members to confirm a nomination to a Reference Group regarding a proposed merger of Norfolk and Waveney Mental Health NHS Foundation Trust and Suffolk Mental Health Partnership.

The Committee agreed to the appointment of Michael Chenery of Horsbrugh as a nomination to the Mental Health’s Trust’s Reference Group.

9 Quality Innovation Productivity and Prevention (QIPP)

The Committee received a suggested approach by the Scrutiny Support Manager (Health) to a report from NHS Norfolk about the Quality Innovation Productivity and Prevention initiative.

During discussion, David Stonehouse, Deputy Chief Executive and Director of Finance, NHS Norfolk, answered detailed questions from Members concerning areas where NHS Norfolk had identified innovation to achieve cost savings in response to the National QIPP initiative.

 Mr Stonehouse said that QIPP was about looking at overall service, and getting partner organisations to work together. It was also about providing opportunities to change the way that the NHS worked as well as delivering quality whilst reducing costs. Mr Stonehouse acknowledged that there were challenges around providing services for an increasingly elderly and frail population, addressing the needs of dementia patients and the needs of people outside of the hospital setting.  The Chairman said that an article in the 7 October 2010 issue of the Health Service Journal had indicated that NHS Norfolk needed to close an anticipated funding gap of £143m by 2013/14 and that 44% of this saving was as yet unidentified. The article had also pointed out that in the current year NHS Norfolk would have to find savings of £30m.  Mr Stonehouse said that NHS Norfolk was expected to break even in this financial year. The pressures on the budget in future years were well known in NHS Norfolk and set out in the report. A draft system wide QIPP plan had been submitted to the Strategic Health Authority and the plan was expected to be finalised by January 2011.  In reply to questions about the out-sourcing of support services, Mr Stonehouse said that this was already done for such services as payroll and estates management. In reply to questions about working with care home providers, Mr Stonehouse said that NHS would welcome an opportunity to build stronger links with a wider range of organisations than had traditionally been the case. He said that getting local teams of health workers and care home providers to work across and within clusters of GP teams was likely to become increasingly important in the years ahead. NHS Norfolk also

- 5 - recognised that innovation in terms of the use of modern technology and forms of communication was becoming more important.

The Committee noted the information on quality innovation productivity and prevention provided by NHS Norfolk.

10 Forward Work Programme

The Committee agreed that their work programme should be as set out in the report subject to :-

“Formation of GP Commissioning Consortia in Norfolk “moved to 3 March 2011.

“Respite- short breaks for carers” to include information about cross-border arrangements for respite, and remain for 20 January 2011

“Autism – Children’s Services “ to be added to 3 March 2011. The report should make clear the diagnostic paths for children to be diagnosed with autism.

The meeting concluded at 12.30pm

Chairman

If you need these minutes in large print, audio, Braille, alternative format or in a different language please contact Tim Shaw on 0344 8008020 or 0344 8008011 (textphone) and we will do our best to help.

T:\Democratic Services\Committee Team\Committees\Norfolk Health Overview & Scrutiny Committee\Minutes\Final\ NHOSC Mins 101015

- 6 - Norfolk Health Overview and Scrutiny Committee 25 November 2010 Item 2

Norfolk Health Overview and Scrutiny Committee 25 November 2010

Glossary of Terms and Abbreviations

COPD Chronic Obstructive Pulmonary Disease

CQC Care Quality Commission

GP General practitioner

ICP Integrated Care Pilots

JPUH James Paget University Hospital

LINk Local Involvement Network

NCH&C Norfolk Community Health and Care

NCS Norfolk Community Services

NHOSC Norfolk Health Overview and Scrutiny Committee

NHS National Health Service

NNUH Norfolk and Norwich University Hospital

NWMH NHS FT/ Norfolk and Waveney Mental Health NHS Foundation Trust NWMHFT

OSP Overview and Scrutiny Panel

OT Occupational Therapy

PCT Primary Care Trust

QEH The Queen Elizabeth Hospital, King’s Lynn

TUPE Transfer of Undertakings (Protection of Employment)

UK United Kingdom

Norfolk Health Overview and Scrutiny Committee 25 November 2010 Item no 7

Norfolk and Waveney Mental Health NHS Foundation Trust and Suffolk Mental Health Partnership – Potential Merger

Suggested approach by the Scrutiny Support Manager (Health)

The Committee will receive a report from the Director of Finance and Deputy Chief Executive of Norfolk and Waveney Mental Health NHS Foundation Trust on the proposed merger with Suffolk Mental Health Partnership NHS Trust.

1. The drive towards Foundation Trust status

1.1 It was the aim of the previous government that all NHS acute and mental health provider trusts should become Foundation Trusts. At the end of 2009 just over half had achieved it. The current government wants all NHS trusts to be Foundation Trusts by 2013/14.

1.2 The intention of Foundation Trust status is to encourage more local control of NHS Trusts and greater financial independence. Foundation Trusts have a membership of local people and staff from whom Governors are elected. Their role is to focus the Trust’s attention on the needs of the community they serve. Foundation Trusts are able to retain and reinvest financial surpluses.

1.3 To achieve authorisation as a Foundation Trust the organisation must meet the requirements of Monitor, the independent regulator of Foundation Trusts:-

 The general requirement to operate effectively, efficiently and economically;  The requirements to meet healthcare targets and national standards; and  The requirement to cooperate with other NHS organisations.

2. The local situation

2.1 Norfolk and Waveney Mental Health NHS Foundation Trust (NWMH NHS FT) met Monitor’s requirements and was authorised as a Foundation Trust on 1 February 2008. It is currently has very good, although not top, ratings from Monitor in terms of its risk ratings for governance and finances. Full details are available on Monitor’s website:-

http://live.monitor.precedenthost.co.uk/home/about-nhs-foundation-trusts/nhs- foundation-trust-directory/norfolk-and-waveney-mental-health-nh

2.2 Suffolk Mental Health Partnership Trust is considered unlikely to achieve Foundation Trust status hence the proposal to merge with NWMH NHS FT.

2.3 The Care Quality Commission (CQC) has registered both Trusts without conditions on their registration. In the CQC’s national surveys of the experience of mental health service users in hospital and in the community the two Trusts have achieved broadly similar results, which are generally about the same as other mental health trusts. The full quality rating for each of the Trusts is available on the CQC website:-

http://caredirectory.cqc.org.uk/caredirectory/searchthecaredirectory.cfm

2.4 The mental health commissioning teams from NHS Norfolk, NHS Suffolk and NHS Great Yarmouth and Waveney and Norfolk and Suffolk County Councils have been working jointly to assess the risks and benefits of the proposed merger from their perspective.

2.5 The mental health trusts have established a stakeholder reference group to which this Committee nominated Cllr Michael Chenery of Horsbrugh. The reference group held its first meeting on 29 October 2010. The next will be on 10 December 2010.

2.5 Suffolk Mental Health Partnership NHS Trust held a public consultation on the proposals, which ended on 31 October 2010.

3 Purpose of today’s meeting

3.1 NWMH NHS FT has been invited to today’s meeting to inform the Committee about the latest developments in relation to the proposed merger and to answer Members’ questions about the implications for mental health services in Norfolk. The Trust has provided the briefing paper at Appendix A for Members’ information.

4. Suggested approach

4.1 After Andrew Hopkins, Director of Finance and Deputy Chief Executive of NWMH NHS FT has presented his report, Members may wish to explore the following areas with him:-

(a) What is preventing Suffolk Mental Health Partnership NHS Trust from becoming a Foundation Trust in its own right?

(b) Is the financial risk rating of the newly merged Foundation Trust organisation likely to be worse than the level achieved by NWMH NHS FT?

(d) How have the Norfolk, Suffolk and Great Yarmouth and Waveney commissioners reacted to the proposed merger?

(e) The merged organisation would become a very large mental health trust. Are there other mental health trusts of a similar size and how well do they perform in terms of quality of service and patient satisfaction?

If you need this report in large print, audio, Braille, alternative format or in a different language please contact Maureen Orr on 0344

800 8020 or Textphone 0344 800 8011 and we will do our best to help.

Norfolk and Waveney Mental Health NHS Foundation Trust & Suffolk Mental Health Partnership NHS Trust Merger Proposal

1. Introduction

The purpose of this paper is to provide a summary of the benefits for Norfolk and Waveney patients that will be realised through the merger of Norfolk and Waveney Mental Health NHS Foundation Trust (NWMHFT) and Suffolk Mental Health Partnership NHS Trust (SMHPT).

The Paper will also set out the process and timetable that is being followed and describes the progress to date.

2. Progress to date

The Trusts have been exploring the potential for how they might work together more closely since January 2010, largely as a result of the future economic prospects for the NHS. These explorations resulted in a joint Board-to Board meeting of the two Trusts in May 2010 in which both organisations agreed that a merger (technically an acquisition of SMHPT by NWMHFT) was in the best interest of the services in both counties.

The two Trusts provide an excellent strategic and cultural fit. The Trusts share a similar vision, common values, aspirations and the demographics of the populations the Trusts serve are very similar. Both Trusts can learn from each other in clinical practice and in cost-sharing opportunities. The combined Trust will be of sufficient size to remain sustainable during the challenging years ahead.

A Programme Board was established in June to oversee the development of a business case and associated commissioning issues, with representatives from both Trusts, NHS Norfolk, NHS Great Yarmouth and Waveney and NHS Suffolk, Norfolk County Council, Suffolk County Council and the Strategic Health Authority.

A draft business case was developed and approved by the Programme Board, both Trust Board of Directors and the PCT Boards. The case was submitted to the Co- operation and Competition Panel for consideration from the competition perspective.

SMHPT completed a public consultation at the end of October. SMHPT were not obliged to have a consultation but felt that as the subject of their last consultation was becoming a standalone Foundation Trust they wanted to consult on the change in approach. NWMHFT have not held a public consultation as no changes to clinical services are currently planned as a result of the proposed merger and NWMHFT are the acquiring Trust. However a Reference Group has been set-up to ensure that stakeholders from both counties are heard at the heart of the process. The first meeting took place on 29th October, Cllr Michael Chenery attended.

SMHPT received a total of 232 responses to their consultation. 61% of the respondents think the merger is a good idea, 32% are not sure. Some concerns were highlighted, including whether a larger Trust would be more impersonal, focus less on inequalities and centralise services. Concern was also expressed regarding job security.

3. Integration Plans

The initial integration plans focus on the amalgamation of corporate and support functions and the alignment of corporate and service governance. This will reduce overhead costs and mean that the efficiency savings required as part of Quality, Innovation, Productivity and Prevention can be realised while protecting funding for frontline services.

Key to the future plans is the organisation of the management of services on a locality based, as they are in Norfolk currently, this will enable alignment with General Practice Consortia and ensure a continued local focus under a clear governance and quality framework ensuring equitable services.

The Trusts are looking at areas of potential clinical benefit and opportunities to improve services. The Trust will, in due course, consult appropriately on any plans to change services. An example of the type of service improvement that is being considered is whether the combined Trust will have sufficient capacity to develop as Child and Adolescent Mental Health Inpatient service so that service users can be treated nearer to their homes, friends and family.

Any plans for changes to services will be developed and made available in due course. Part of the approach to ensure that the merger does not detract from the operational running of the services in both counties is to focus initially on amalgamating corporate and support areas safely before considering service changes. Any service changes will follow appropriate planning and consultation.

4. Benefits for Norfolk Patients

These benefits can be identified from the high level objectives of the merger (which are laid out in the business case) as follows:

1. Improving clinical care by spreading the best practice from each Trust into the other. The Trusts have identified significant potential improvement to services.

A number of examples are given in the business case, but specifically for Norfolk and its patients is the opportunity for Norfolk to learn from some of the innovations that Suffolk has undertaken in developing liaison services with Acute Trusts, the extensive range of service user involvement activities that take place in the Trust and the fact that Suffolk provides learning disability services will help us to ensure that our mental health services are better organised to meet the needs of people with learning disability who also have mental health problems.

2. Expanding innovation, teaching and research. The larger, combined Trust will have access to NWMHFT’s strong research base and the opportunity to become part of the Health Innovation and Education Cluster hosted by NWMHFT which is dedicated to the needs of older people. This has benefits both for research and for the service. It is fair to say that SMHPT does not have a well developed research function. However, the coming together of the two organisations presents opportunities for the new Trust to undertake more wide ranging research activities. Suffolk’s population has very similar public health and demographic indicators to that in Norfolk and so innovative new treatments/models can be implemented quickly across both counties.

3. Creating greater choice for service users. Combined, the Trusts will be able to provide greater choice of teams and clinicians for individual service users.

Greater choice can be offered to patients in two ways. Firstly, different expertise and styles exist across similar services in both Trusts and by developing these in a systematic way, new approaches, treatments and therapies can be introduced to Norfolk. Secondly, we will be able to offer a wider alternative of choice to patients in terms of second opinions or an alternative team for referral should there be any dissatisfaction with treatment from a particular team.

4. Bringing together the capabilities of the two Trusts will ensure a more efficient and effective organisation. One which can be more responsive to patient needs and the requirements of commissioners. At the same time, by exploiting economies of scale, make a significant saving to contribute to the wider objective of reducing overhead and other costs without impacting on frontline services.

The NHS is now operating in a difficult financial environment. There are massive expectations of the NHS and improving service quality at a time when income is reducing and efficiency assumptions are being raised to new levels. This merger provides the means for meeting that efficiency requirement through a significant reduction in the overheads of running two organisations by moving to a single organisation. Savings achieved in this way will help to protect the funding available to support front-line care. Each of the three PCTS will benefit proportionately from this saving in terms of the Trust meeting efficiency targets over the next three years.

5. A larger Trust will be strongly placed to develop new specialist services, increasing accessibility and scope of services in East Anglia and its contribution to the public health agenda.

There a number of additional services that the new Trust could develop that would bring benefits to the people of Norfolk. The combined size of the new Trust provides an opportunity to develop Tier 4 CAMHS services and expertise and in particular in-patient beds, which with more local provision would prevent families having to travel to Cambridge and beyond to where these services are currently located.

6. A larger Trust will offer staff more opportunity. For example, greater critical mass will enable the offering of training of all types efficiently, and will also ease recruitment difficulties. Size will also assist in managing change, with more opportunities for development and redeployment.

This will be true for all staff, whichever county they work in. Part of ensuring a motivated workforce is for staff to see and have access to opportunities for development. A number of studies have shown that a motivated workforce provides better patient care. 7. The coming together of the two Trusts will strengthen existing partnerships and build new relationships to promote joint working across organisational and county boundaries.

This will help to reduce transaction costs – both Trusts have relationships and contracts with all three PCTs and both County Councils for example. The new Trust will base its services in localities, which will link in well with GP Commissioning Clusters. The Trust envisages that Localities will work closely with GPs to develop services in their particular area.

From a commissioning perspective, the merged Trust will provide the opportunity for commissioners who wish to increase contestability of mental health services, to put more services out to tender. Each Trust on its own is probably too small to stand losing a whole part of its service (e.g. a locality), but a combined Trust would be more capable of dealing with such changes.

A combined Trust can achieve the critical mass to work even more closely with local authorities keen to embrace their new role in addressing health inequalities through care pathway redesign and partnership working.

5. Timetable

The merger is subject to a number of approval processes, which are set out below. Some of the suggested timings are subject to change, but the Trusts are working towards 1 April 2011 as being the start date for the new organisation.

 Support was given by Primary Care Trust Boards during September/ October 2010.  Support is also being sought from the SHA and the business case will go through the SHA Board in January.  The draft business case is with the Co-operation and Competition Panel for their assessment – expected in January/February 2011.  Business Plan and 5-year financial model to be submitted to Monitor in November 2011 for their assessment, with outcome expected by March 2011. NWMHFT Trust Board will then decide on whether to proceed with the merger following Monitor’s assessment - expected March 2011.  NHS Transactions Board to review the proposal, following the PCT and SHA deliberations.

Norfolk Health Overview and Scrutiny Committee 25 November 2010 Item no 8

Provision of Primary Care at Terrington St John

Suggested approach by the Scrutiny Support Manager (Health)

NHS Norfolk will give a verbal briefing on the provision of primary care from temporary premises at Terrington St John. The Committee will have the opportunity to question managers on the arrangements for accommodating the service.

1. Introduction

1.1 The GP partnership which formerly ran the practice at Terrington St John has dissolved and the contract for provision of GP services in the village has been awarded to First Health, a Peterborough based primary care company.

1.2 The outgoing partners and First Health were not able to agree a price for the sale of the surgery building and the difference between them was so wide that it was not possible to broker a deal.

1.3 This meant that temporary accommodation had to be found when First Health took over the practice. An NHS Norfolk press release dated 18 October 2010 said that the interim premises could be in the form of mobile units in the village or could be existing community space. In the event, the practice moved into the Scout hut in Terrington St John and has been operating from there since 1 November 2010.

1.4 The Scout hut is still in use for other community activities and the GP practice moves its equipment at the end of each day. There is no land-line telephone so the practice is operating on two mobile phones.

1.5 NHS Norfolk has ordered mobile units as new temporary premises for the practice to be sited on the same land as the Scout hut. These are scheduled to arrive on site on 20 or 21 November and should be fully operational by early December 2010. A land-line for the Scout hut has also been ordered from British Telecom as a matter of urgency.

1.6 In the longer term NHS Norfolk will work with First Health to ensure there are permanent premises in Terrington St John. One option is a new build, which would be the second new surgery in the village in just over 10 years. GP practices, all of which are private businesses, provide their own premises usually by obtaining a mortgage to build. NHS Norfolk then pays the GP practice rent for the use of the building.

2. Dissatisfaction with the temporary arrangements

2.1 The practice at Terrington St John serves 6,500 people and concerns about the current situation have been raised with the local County Councillor. The primary issue is that people are finding it difficult to contact the practice on its mobile phones at the Scout hut.

2.2 There is also concern about the logistics of a GP practice having to vacate its rooms at the end of each working day.

3. Purpose of today’s meeting

3.1 NHS Norfolk has been invited to give this Committee a verbal briefing about the current situation at Terrington St John. Members will then have the opportunity to ask questions about the arrangements for temporary accommodation of the service.

3.2 The Committee’s role is to focus on whether the local NHS is delivering an acceptable service to patients. Local County Councillors have been invited to the meeting to inform the Committee of local views.

4. Suggested approach

4.1 Members may wish to explore the following areas with NHS Norfolk:-

(a) Exactly where will the temporary mobile units be situated and what size will the new temporary accommodation be?

(b) Can NHS Norfolk explain why temporary mobile units were not ordered sooner?

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800 8020 or Textphone 0344 800 8011 and we will do our best to help.

Norfolk Health Overview and Scrutiny Committee 25 November 2010 Item no 9

Hospital Discharge Processes

Suggested approach by the Scrutiny Support Manager (Health)

The Committee will receive an update report from Norfolk Local Involvement Network about its work on patients’ experience of hospital discharge from Norfolk’s acute hospitals.

1. Introduction

1.1 In November 2009 Norfolk Local Involvement Network (LINk) presented a report to this Committee about its work on hospital discharge processes and the patients’ experience. At that stage it had recommended to the hospitals that they establish the following:-

1. A formal record of the discharge plan for patient and family 2. An evaluation checklist – for all patients to be discharged - to score items such as medical care received 3. A patients and carers leaflet at the bedside of all inpatients.

1.2 Norfolk Health Overview and Scrutiny Committee (NHOSC) invited Norfolk LINk to report back at a future date with its views on whether the acute hospitals had improved their patient discharge processes. LINk will be presenting that report today (Appendix A).

2. Suggested approach

2.1 LINk’s report has raised issues that the Committee may wish to pursue with the hospitals concerned. Representatives from the Queen Elizabeth, Norfolk and Norwich University hospitals have therefore been invited to attend today’s meeting. After hearing the presentation you may wish to question them on the following issues:-

(a) What is their reaction to the LINk proposal to have a named, key person(s) who has responsibility for engaging with patients and their families in discussing discharge and who is accountable for identifying and progressing any actions. This person(s) would need to have influence over all the agencies and professional groups involved.

(b) What is their reaction to LINk’s proposal that it should be a rule rather than an option that Community social work teams continue to work with people admitted to hospitals where they already hold case responsibility.

3. Action

3.1 LINk has asked NHOSC to do four things (see section 5, p.7 of the report attached at Appendix A). These are set out below, with suggestions in italics on how the Committee may wish to respond:-

1. To endorse LINk’s idea for hospitals to have a named, key person who has responsibility for engaging with patients and their families in discussing discharge and who is accountable for identifying and progressing any actions.

Following discussion at today’s meeting NHOSC may wish to decide whether to support LINk’s recommendation.

2. To monitor closely the objectives and outcomes of the integrated care pilots to ensure good practice becomes embedded in the health and social care system in Norfolk.

NHOSC may wish to ask the newly established Integration of Service Delivery joint task and finish group with Community Services Overview and Scrutiny Panel to take account of LINk’s recommendation.

3. In respect of the telephone-based social care assessment service, Norfolk LINk would prefer that it is a rule rather than an option that Community social work teams continue to work with people admitted to hospitals where they already hold case responsibility. Currently this is presented as an option in Norfolk Community Services customer pathway map. LINk wish the appropriate scrutiny panel to endorse this.

Following discussion at today’s meeting NHOSC may wish to decide whether to support LINk’s recommendation.

4. Norfolk LINk spans both health and social care providers and has identified flaws and gaps in both the health and social care systems. However this is not the case in respect of the overview and scrutiny committees. Given the drive towards integrated services, this separation of function seems to us counter-productive and gets in the way of improving services. In the short term we want to see very close liaison between the existing scrutiny committees in order to accomplish the goal of a properly integrated service and ‘seamless hospital discharge’. With the possible reorganisation of scrutiny functions, the opportunity should be taken to develop a service which covers both agencies.

LINk’s suggestion is very relevant in the context of the drive towards closer integration of health and social care in the health White Paper. Scrutiny arrangements are likely to change as the White Paper proposals are introduced and the Council will be considering all its

options.

In the meantime the Chairmen of NHOSC and Community Services Overview and Scrutiny Panel will continue to co-ordinate work programmes through the Overview and Scrutiny Strategy Group.

If you need this report in large print, audio, Braille, alternative format or in a different language please contact Maureen Orr on 0344

800 8020 or Textphone 0344 800 8011 and we will do our best to help.

Norfolk Local Involvement Network (Norfolk LINk)

Title of paper: Leaving an acute hospital – the patient, family and carer’s experience Submitted by: Norfolk LINk’s Hospital Discharge Monitoring Team Submitted to: Norfolk Health Overview & Scrutiny Committee Date: For 25.11.2010 meeting in public

Contents: 1. Background 2. What happened next? 3. The carer’s story in 2010 4. What has changed since 2009?  Social care  Acute hospitals – NNUH, JPUH and QEH; overview  Integrated care pilots 5. What does LINk want NHOSC to do? 6. Conclusion

Abbreviations used NNUH - Norfolk & Norwich University Hospitals NHS Foundation Trust QEH - Queen Elizabeth Hospital NHS Trust JPUH - James Paget University Hospitals NHS Foundation Trust NCS - Norfolk Community Services (previously known as Norfolk Adult Social Services)

1. Background

The 2009 Norfolk LINk survey of patients’ experiences of hospital discharge suggested ways that hospitals could improve the discharge process for patients and their families. These suggestions revolved around improving communication so that patients and families were well-informed throughout their hospital stay, in particular, prior to discharge and could actively participate in the planning and delivery of their health and social care.

2. What happened next? Since June last year LINk members met with hospital staff, social services and the Norfolk Primary Care Trust to discuss these ideas. As a result of these discussions the LINk discharge team decided to focus their efforts on promoting proper coordination within hospitals and between all agencies involved in patients’ care. LINk is of the view that this would be best done by having a key, named person in the hospital who is responsible for:  organising all the various services and interventions which the patient needs  identifying and chasing up those who will provide them  monitoring progress and  ensuring accountability. Crucially, this ‘key’ person (or persons if this is ward-based) would be the contact person for patients and families to turn to when they need information particularly around arrangements to do with leaving hospital.

The above decision on changing focus was partially as a result of the initial lukewarm response from two hospitals. More importantly it was because of what patients and their families were telling LINk in 2010: that clear and simple, verbal communication and continuing discussion is essential when someone is feeling very unwell (patient) or worried (relative/friend/carer).

3. The carer’s story in 2010

(Sentences in quotes are the carer’s own words and those in italics are LINk views.)

Mrs K is in her early 70s and is the carer for her 87 year old husband who died at home in September 2010. She rang the Host office to share with LINk her experience:

She had an “awful time” when her husband was hospitalised in May this year for 57 days at Edgefield Ward, a surgical ward at the NNUH. He had Alzheimers, COPD and cancer of the bladder. She knew he was not going to recover from the cancer – “you only had to look at him”. She asked repeatedly when he could go home so that she could care for him at home but information about an expected discharge date was not offered or discussed. Responses from ward staff were generally unhelpful e.g. “Can’t discuss discharge without meeting with social services”.

2 His health was deteriorating progressively – she felt that this was because he was not eating properly in hospital. Her offer to help feed him was turned down because she was told by a staff member that the patient had signed a form saying he was capable of feeding himself. (“He has Alzheimers, if you asked him to jump off the building, he would have said ‘yes’”) As she was worried that he was not eating enough, she contacted the specialist mental health nurse to ask for some help. The latter said he/she could not intervene because her husband was not on a Medicine for Elderly ward. (Is this an example of professional barriers impeding the overall care of the patient?)

In desperation she raised her worries with a colleague on the Osteoporosis Society, Patrick Thompson, who is also Chair of LINk’s Strategy Group. This led to Anna Dugdale, Chief Executive, NNUH being personally alerted to the situation. She intervened immediately by visiting the ward and asked staff to give her regular updates about Mr K’s uptake of food. Although thankful for this, Mrs K felt that it is not right that a carer or relative has to make lots of ‘noise’ before the patient can get the basic care he needs. “What about those people who don’t make a fuss?” She said that because of her husband’s long stay in hospital, she overheard many visitors of other patients wondering about ‘disturbing’ the nurses to ask for information and she would advise them to just ask. Mrs K emphasised the lack of communication from ward staff: “There was no one to talk to, to get any information …No one comes to talk to the visitors”.

She felt that the ward nurse only took notice of her repeated requests to discharge her husband when she said “I want to take him home to die” – saying that the word “die” appeared to make the difference. As a result Mr K was to be fast-tracked for discharge – she was surprised to learn that this meant three weeks! Fortunately the next day, a Manager from Hales Care (Norwich) visited her husband and said almost immediately that Mr K should not be in an acute hospital. This manager arranged for Mr K to be discharged home by the end of the week. On Mr K’s return home, Hales Care arranged for him to receive care from their staff which Mrs K thought was very good. Mrs K stated that during Mr K’s hospitalisation, she did not have any meeting or discussion with a social worker.

She was so distressed during her husband’s hospitalisation that she even rang MacMillan Nurses in London for advice. (In 2011 the LINk discharge team will be looking at ways of improving links between hospitals and local voluntary groups.)

Mrs K said that the best people on the ward were the night staff who would take the time to talk to the visitors and knew “lots”. She said that 20 years ago, her experience was that there would be a Nurse at the door of the ward welcoming visitors and who would be the key person for relatives and carers to get information from – but now there is just no one to talk to.

Below is a summary of several issues that the previous story highlights:

 Poor communication between staff and patient/family within ward – including unwillingness to spend time discussing with carer/spouse the reasons for lack of definitive information and apparent dismissal of carer’s feeding concerns.  Not fully taking into account patient’s mental health condition.  Lack of professionalism – not sharing nutritional concern with relevant staff member.  No social worker alerted or involved in 57 days of care.  No palliative care plan in place or if set up, not shared with carer.  What about those patients, carers and families who do not ask or persistently ask for information?

Although this story is anecdotal, we believe it depicts the type of experience that a small number of people are experiencing in acute hospitals in Norfolk. Whilst it is likely that the majority of patients have good experiences of discharge (because we are told by the hospitals that 80% are ‘straightforward’ discharges), the small number of people affected adversely tend to be the very ones who need good and timely support from the NHS and allied organisations. There are other examples of patient experience documented in Appendix 1 which have been passed to LINk from members of the public and representatives from Age UK Norfolk and First Focus of Fakenham (a voluntary organisation offering support to stroke patients).

4. What has changed since 2009?

1. Social care Norfolk Community Services – A telephone-based assessment service run by Norfolk Care Connect is being extended, from the middle of November 2010, to deal with those hospital discharge cases who require straightforward post-hospital care. The service would enable straightforward support to be put in place quickly e.g. re-starting a continuing care package; helping people with baths and shopping; or accessing equipment/aids to prevent falls. Hospital-based social workers will reduce in number with those remaining dealing mainly with discharges requiring complex post-hospital support. In addition, we have been recently told that a few staff from Norfolk Care Connect will be based in each acute hospital to provide, if needed, face-to-face assessments for those with less complex needs but requiring the personal discussion. The new telephone-based assessment system will enable a patient, carer, GP, member of the public or hospital staff member to phone one number where the call taker, if necessary, can pass them directly on to a social worker or assistant practitioner. The latter will be able to assess the client immediately and arrange or signpost support. Previously a caller would have to wait to talk to a social worker to receive an assessment. With the new system, this wait should no longer occur unless the needs involved are complex in which case a face-to-face meeting will be arranged. We have been told that face to face meetings will also continue to occur for individuals with learning difficulties or mental health concerns. Social workers assigned to a patient through GP surgeries will be encouraged (the monitoring group believes that this should read ‘expected’) to follow the same patient through hospital admission and discharge.

Norfolk LINk has been closely involved and consulted in this change of system. Members have asked that hospitals and GPs be informed and involved in the change. We are pleased to note that social services are rolling out training and support to acute hospitals in November so that the transition is smooth.

Norfolk LINk has some reservations about the new telephone-based assessment service - mainly that an over-reliance on telephone conversations may not inform the social worker about the real state of affairs surrounding a few patients. Although LINk appreciates that this initiative is spearheaded by governmental drive to move care more towards and within the community, assessment by telephone of someone in a hospital bed who is, by definition, ill and may also be confused or sedated is problematic, particularly as they will normally be deprived of access to advice from family, friends or other professionals. We are however pleased to hear that a few Norfolk Care Connect staff will be based at each hospital and hope they will provide the face-to-face contact whenever necessary. LINk will monitor the progress of this new system.

2. Acute hospitals - discharge process

The group has met with all three acute hospitals to present its research report and discuss the implications.

NNUH – We are pleased to report that LINk reps are currently members of the hospital’s Discharge Steering group where the idea of a ‘key worker’ to fully co-ordinate all discharge- related activities is being discussed. One outcome is that one or two wards in the Medicine for Elderly department will be piloting this idea in the near future. Also, LINk has made comprehensive and detailed comments on the hospital’s Discharge Policy and Protocol document. Among other things, a statement ensuring that patients and families are put in the centre of all discharge-related planning work is to be included. Participation in this group has led to the hospital staff welcoming LINk input as constructive and helpful; and the team are optimistic about potential improvements albeit at a slow pace.

JPUH – We have only had one meeting with the discharge staff from this hospital, when the Case Manager for Medicine offered to be the central referral point for patients to discuss discharge arrangements as early as possible since she sees all the patients in the Medical wards. LINk is currently in the process of seeking more information about the impact of this for patients and families and will pass any update to the Scrutiny Officer. Also, JPUH has devised a simple and useful discharge checklist for staff -10 steps for timely discharge planning - which we would recommend NNUH and QEH to use as well. Pending further discussions, which have been delayed because of staff changes, we are pleased that staff were open to LINk’s survey suggestions and are actively looking at improving the ‘talking to patients and families’ aspect of discharge.

QEH – The hospital has now put in place a Discharge planning team to expedite the discharge of non-elective patients. Nine out of fourteen wards will be helped by this team who are made up of Discharge Planning Coordinators (trained nurses) and planning assistants (not nurses). The latter will help patients with simpler aspects of discharge e.g. getting the keys of the house. It is envisaged that the planning team’s work will expedite timely discharge which LINk would warmly welcome. A positive development by the end of this month will be 5 the transfer of responsibility for intermediate care referrals from the PCT’s own hospital-based team (a longstanding anomaly) to the QEH’s own Discharge Planning coordinator. The move towards having one referral form for assessment instead of two should help expedite discharge proceedings. LINk commends these two moves as positive measures in improving the patient and family experience of hospital discharge.

Unfortunately we are unable to offer any of our own observations or an informed view about improvements in communication with patients and families, because of the resistance to any close involvement by QEH in spite of three visits to the Hospital in the last nine months. At our most recent meeting we were told that there were no discharge planning groups or committees that LINk could take part in to represent the patient and public perspective. There is an offer to contact us next year for assistance in revising their admissions and discharge policy (although the policy states it is due for revision late this year) but similar offers in the past have not come to fruition.

Overview of discharge process at acute hospitals Although all the acute hospital trusts are trying to improve their coordination of services within the hospital, far less attention is given to communication across the ‘boundaries’ with other agencies, particularly primary care workers and, to a lesser extent, social workers. There is accordingly little real sign of truly integrated working and professional barriers remain high. For example we were told that hospital discharge planning assistants (at QEH) would be unable to expedite or “chase up” service delivery by social services and could not even discuss discharge care with a primary care nurse, for example, because “they (the QEH assistants) were not themselves nurses”. We have real concern that these unhelpful aspects of professionalism will persistently frustrate attempts to give the patient/client a seamless service which, it is claimed, is the intention. The LINk goal remains that a named coordinator should have influence and accountability across the agencies.

3. Integrated Care Pilots (ICP) – ICPs are initiatives to develop integrated care in Norfolk amongst commissioners, providers of primary and secondary health care, and social services. Norfolk LINk reps are involved in these around the county. The King’s Lynn ICP is focusing on hospital discharge and is appointing a coordinator to test out some aspects of the role to which we have referred above, although the precise details are not yet clear. The LINk representative on this pilot is also part of the LINk’s discharge team and so will be well-placed to input into the pilots. The same LINk representative will be working with the scrutiny panel which is about to examine the achievements of the ICPs.

5. What do we want NHOSC to do?

2. To monitor closely the objectives and outcomes of the integrated care pilots to ensure good practice becomes embedded in the health and social care system in Norfolk. Perhaps this will be for the consideration of the scrutiny panel being set up to look into integrated care pilots?

7 6. Conclusion

Acute hospitals and social services have been busy putting in place numerous initiatives and projects to improve their hospital discharge process. However these we feel have been largely from a management perspective (i.e. looking at managing numbers) and not about enhancing the experience of patients, carers and families. Based on our participation in hospital committees and access to the PCT’s Commissioning Board papers, our observations are:

 Some of these initiatives do improve the patient experience (e.g. enablement pilot project at NNUH) but they appear to be inconsistently applied across hospitals and are often dropped for lack of money (e.g. a pilot) or because of newer initiatives.

 There is no real integration between acute hospitals, GPs, social services and other agencies. Each group appears to develop its own multi-faceted systems of work without informing or involving other agencies from the outset. The exception so far has been Norfolk Community Services (NCS) who are providing induction training opportunities to all acute hospital staff so that they know how to access the Norfolk Care Connect system for their patients. We are also pleased to note (through NCS) that acute hospitals are going to work towards having a common criterion to define ‘delayed discharge’; currently each hospital has its own definition of ‘delayed discharge’.

We appreciate that staff in all of Norfolk’s acute hospitals provide the majority of patients with a high level of professional and excellent care, in the face of ever-increasing demand for hospital beds and social care support. However, coordination, especially between hospitals, primary care services (including GPs) and social services remains problematic.

The appointment of a ‘key worker’ or ‘case worker’ would enable patients and families and all the other professionals involved to be fully engaged with the discharge process. In particular, patients would be empowered to participate actively in the decisions which are made about them. LINk is of the view that this step would be likely to lead to fewer hospital admissions, re- admissions and shorter lengths of stay.

Our thanks to Age UK Norfolk, Age UK North Norfolk and First Focus Fakenham and those members of the public who have helped inform this report.

Report authors:

Terry Allen, Morag Skinner and Margaret Young Norfolk LINk - Hospital Discharge Monitoring Team. Report compiled by LINk Facilitator, Carole Ponniah

12.11.2010

8 Appendix 1: Norfolk LINk report on hospital discharge to NHOSC 25.11.10

A short list of examples in 2010 of poor hospital experience including hospital discharge

1. From member of the public:

A 72 year old male with Parkinson’s Disease was admitted to Dunston Ward at the NNUH in August this year with an acute urinary infection. The infection responded well to antibiotics and cleared up within 2 weeks. During this time the patient had one visit from a physiotherapist. After the two weeks, the patient’s wife asked the Occupational Therapist to put in a referral to see a Social Worker as she felt that she needed some assistance at home when her husband was discharged. Five days later she asked the staff nurse about the referral and the staff nurse said she had made it the day before.

During the patient’s entire stay at hospital, he received a small amount of physiotherapy but did very little walking. Consequently he tried to swing his legs over the edge of the bed to improve his circulation but was manhandled back into bed and was given no chance to explain what he was trying to do. This distressed him. As a result of this inactivity he began losing the little mobility he had and lost 6 kilos in weight.

After 24 days in the hospital where he had received minimal physiotherapy and was not allowed to practice walking around by the ward staff, the patient’s Consultant said he would probably do better at home. The patient’s wife then told staff that she was discharging him as he was getting weaker and more depressed. A Social Worker and Occupational therapist then came to see them. This was the first visit they had received from a Social Worker. The patient left hospital the next day.

The good news is that since leaving hospital, social services were providing the necessary support.

The patient’s wife said that during this whole episode:

 There was no evidence of any Care Plan in the hospital  She felt frustrated that there was no one person she could ask about what was happening.  Staff from the different disciplines did not seem to be talking to one another. “There was no joined up thinking”.  It took nearly 2 weeks from asking for help to seeing a Social Worker.  At no time was a date given for possible discharge.

1 The following examples were passed to us by Age UK Norfolk. The co-ordinator obtained the information when she talked to the individuals during home visits and from her own observations.

2. Example of Mr and Mrs C in Dereham area

Mrs C – a female, in her 80s living with similarly aged spouse. She had diabetes, mobility issues, kidney shutdown and was approaching the terminal phase of her life. There were several failures across all sectors from GPs, district nurses, out of hours services, ambulance staff, social services and acute hospital staff.

Mr and Mrs C were told about Mrs C’s impending death by the consultant in a manner that upset both of them. Mr C was told on his own; he was shocked and did not understand the medical terminology. There was no offer of support or a follow-up visit by anyone. They both found it extremely difficult to talk to each other about the impending death and the necessary arrangements to put in place prior to this.

She was in and out of the NNUH frequently in the last 6 months of her life. This involved paying for hospital parking for every trip although the couple are on benefits. No one at the hospital told them that they could get help with this and the other social care support that they could have asked for. There appeared to be little awareness by the GP about the couple’s circumstances (that they needed some additional support). There did not appear to be a hospital social worker who was assisting them – presumably because Mrs C was in and out of hospital so frequently. There was certainly no palliative or end of life care plan that the two of them were aware of. During her many visits to the hospital, the couple would sit waiting to be seen, sometimes for many hours as they were afraid to miss their turn. They were both diabetic but no one would think to offer them a cup of tea or biscuit.

When the coordinator met them for the first time she realised very quickly that the husband could not read; that Mrs C was the ‘reader’ for both of them but could no longer do this because of her illness and a visual impairment. The co-ordinator was worried about the dispensing of medicines by the husband.

The co-ordinator was at the house on a cold and snowy February day when Mrs C was brought home by ambulance staff, wheeled in on a trolley with a thin hospital gown on, a thin blanket over her and a plastic bag of her clothes by her feet. No one had bothered to help her put on a jumper from the bag to keep her warm. When surprise and concern were expressed, the ambulance staff reassured them that the heater had been on in the ambulance. Ambulance staff could not place Mrs C in a chair because ‘they were not trained to use a hoist to lift her into the chair’. They were able to lift her into her bed. Her spouse had to wait for carers to arrive to help his wife out of the bed and into the chair as he himself was unwell, having been diagnosed with prostate cancer several months ago.

A care package was arranged which worked but this was at times inconsistent. In the last couple of weeks as the illness progressed, she was struggling to swallow but no district or palliative care nurse came to visit or to check on her. A volunteer from Crossroads came to sit with her so that her husband could have a break to go and do their shopping.

During the last 6 months or so of her illness, the GP only got involved when her diabetes readings rang alarm bells. At these times, Mrs C’s husband would call for the paramedics -

2 this was a fairly regular occurrence. On one occasion when the GP was called out, the GP did not know how to change the urine bag so the spouse had to show him.

When Mrs C was admitted to the Emergency Admissions Unit for the last time (in May), she was almost unconscious and was taken up to a ward to die. Her husband of 57 years was distraught – he was told of her death by telephone in the early hours of the morning and when he was alone at home. He had always wanted to be with her towards the end. Mr C was not offered any bereavement support.

LINk view

This couple were both clearly fragile. He was in his early 80s and showed signs of memory problems, lack of stamina and interest about things around them. He was her main carer and was dealing with his own cancer at the same time. In addition, the couple are from a generation or culture who do not like to complain, are embarrassed to ask for help in filling out forms or to say they do not understand the contents of a form. The PCT sent them a questionnaire about satisfaction with NHS services generally which they did not complete. It was 8 pages long.

The Age UK coordinator and the LINk team strongly feel that if professionals spent some time talking to patient/family members, many of these issues could have been picked up and tackled quickly and inexpensively. This example reiterates the point that a paper document is certainly of little assistance for carers and families when a loved one is hospitalised as they are usually distracted or distraught with worry about the patient; and similarly the patient may not be well enough to take in important information – and this is assuming there are no other underlying factors present such as literacy, mental health, disability or language issues. This example highlights the following specific concerns:

 Poor skills in telling family that illness was terminal  Lack of ‘real’ and ongoing GP involvement throughout the patient journey - getting to know your patient and the family situation  Lack of communication between patient/family and all NHS and social care organisations so that the needs of the patient and family are not picked up EARLY  No adequate home care arrangement/package in place before her acute hospital discharge & poor quality of social care on discharge  No contacting of voluntary groups by hospitals for assistance  No end of life care package in place  Patient and family do not know what is available or what they can expect

3. Example of D, central Norfolk area

This is about a lady in her late 80s, living on her own and who has a curvature of the spine which means she is permanently bent over at an almost 45 degrees angle. She has Parkinsons disease, cannot see very well and has significant mobility problems. She was found collapsed one Sunday morning in May because fortunately a neighbour saw her through the front window, lying on the floor. As no arrangement had been made with the neighbour or anyone else about access to a key, key safe or personal alarm, the neighbour rang a family member who lives elsewhere in the county. The latter rang for an ambulance who broke down D’s door to get to her. No one knows how long she had been lying on the floor. She stayed at the NNUH for about 8 weeks and was home for 12 weeks when the coordinator visited her and subsequently heard about D’s story.

At the hospital D was told that she needed to have 24 hours monitoring of her blood pressure through the GP service but this was later declined by the GP practice. D was asked to walk up and down in the hospital as part of her Occupational Therapy (OT) assessment. To be able to sit on the low sofa at home, she was told by the OT to press her calves against the sofa then sit down. The OT helped her to get ready to leave the hospital and also made contact with D’s niece who arranged to have the bed at home brought downstairs. This was done but unfortunately no other arrangements were made – there was no commode, no grab rails and no guard rails for the bed. The hospital gave her a zimmer frame to use – however this was not helpful as she has to lift the frame to move. When the coordinator met her in June after being discharged from hospital, she was dragging herself up the stairs about four times a week. The coordinator felt that the assessment would have been more accurate and helpful if a home assessment had been done as a visit would have revealed that there were many possibilities for a nasty fall e.g. carpet, polished floors etc.

The family arranged for an electric heater for D because she has no central heating and could no longer safely start a fire in the fireplace. She leaves a note hanging out of her postbox saying to callers to bang on the window to get her attention as she is disabled and will take some time to answer the door. This raises issues about her personal safety. All of this supports the view that care assessments need to be done perhaps both at the hospital and in the home before discharge.

D receives a care package that involves a carer visiting once a day but her situation is not safe – she could fall. No one in the hospital contacted the voluntary groups to ask for assistance. From the co-ordinator’s experience, this connecting up with other organisations is not happening.

Specific issues raised:  Lack of home visits for OT and social care assessments resulted in poor post-hospital arrangements in place  No linking up with voluntary groups who can offer ‘free’ volunteer assistance Regarding this, LINk has also received confirmation from Age UK North Norfolk - Margaret Craske, member, and Sally Martin, Manager of Capacity and Access Team - that they are concerned about the lack of co-ordinated working between voluntary and health/social care organisations.

4 4. Example: Case E

93 year old lady, living alone, was discharged from acute hospital in the evening. The family who live outside Norfolk had informed the hospital about their contact details. She has a care package but no one was there to meet her at home on discharge. The Red Cross Home from Hospital service had not been informed about her discharge or her need for assistance. Although she has a care package, the family have had to make their own contact with various agencies, including the Red Cross Home from Hospital group, to make sure that she is not discharged in this way in the future. They are extremely anxious that, should this occur again, she should have something in place on her return home as they do not live in the County and are therefore unable to help physically. Main concern:  No carer at home on discharge

5. Example: Case F

F is a young woman who has learning difficulties and was admitted to NNUH briefly. After she was told that she could go home, she had to wait from 8am to 2 pm for medication to be dispensed from the hospital pharmacy. No one explained to her what was happening. Concern:  Lack of communication to vulnerable patient about long wait for medication following discharge

6. Example: Case G

G was admitted to an acute hospital in Norfolk for a hernia operation. She is deaf. She told the Age UK coordinator that no attempts had been made to ensure that she heard and understood what was being said to her while in hospital. She had to arrange her own transport and had no assessment or care package in place on her return home, despite living alone. She had no contact from the GP surgery after discharge either. Concerns:  Not taking into account patient’s disability in hospital discharge process  Lack of post-discharge arrangements or follow-up from GP

LINk has also received three examples of poor hospital discharge experience towards the end of 2009 from Brenda Coldrick, representative of First Focus of Fakenham. Below is one example: 7. Example: Case H He was visiting Harlow when he had his stroke and was in Harlow Hospital for 2 weeks, then moved to QEH where he remained for 6 months. He was taken to his home and left inside the front door. Paralysed down the left side, H’s brother had to visit him at home that first morning to get him up as the carer did not turn up. The next day the carer came to give him lunch. When he wanted a cup of tea, a paramedic helped him on one occasion but there was clearly an inadequate care package in place. This is when H’s brother contacted First Focus for help. The latter contacted Social Services who organised a re- admission into a care home. He is there permanently now.

Concern:  No adequate care package in place prior to hospital discharge  Lack of professionalism from ambulance staff

Norfolk Health Overview and Scrutiny Committee 25 November 2010 Item no 10

Norfolk Community Health and Care

Suggested approach by the Scrutiny Support Manager (Health)

The Committee will receive a presentation from the Chairman and Chief Executive of Norfolk Community Health and Care on the implications of the former NHS Norfolk community services provider arm moving towards Community Foundation Trust status.

1. Background

1.1 The previous government introduced the aim that NHS services should be commissioned and provided by separate organisations. Primary Care Trusts were the commissioners of almost all NHS services for people in their areas but they also directly provided community health care including community services, health visiting, physiotherapy, speech and language therapy, sexual health services and a range of other services. The previous government expected Primary Care Trusts (PCTs) to work towards divesting themselves of their community services arms and the current government wants the process to be completed.

1.2 There are several options open to the community service provider arms, including:-

(a) Establishing themselves as social enterprise companies (b) Becoming NHS Community Foundation Trusts (c) Integration with NHS acute hospital trusts or mental health trusts (d) Disbanding (staff would transfer under TUPE to whichever other NHS or private provider won the contract to provide community services).

NHS Norfolk and its provider arm, Norfolk Community Health and Care (NCH&C), have opted for the Community Foundation Trust model.

1.3 On 13 February 2009 the Director of Service Integration and Market Development at NHS Norfolk wrote to Norfolk Health Overview and Scrutiny Committee seeking the Committee’s views on its plans for the development of out of hospital care and its preferred option of establishing its provider arm as a Community Foundation Trust. The Committee responded as follows:-

‘The Committee welcomes integration of care for people across organisational boundaries and wishes Norfolk Community Health Care well in its journey towards becoming a Community Foundation Trust.’

1.4 The health White Paper in July 2010 announced the abolition of PCTs in April 2013, after which it is expected that GP consortia will commission community health services.

1.5 As a Community Foundation Trust, NCH&C would continue to be an NHS organisation and would potentially compete with private health care organisations for contracts let by the GP consortia to provide community healthcare in Norfolk.

2. The current situation

2.1 NCH&C was awarded independent NHS Trust status on 1 November 2010. This means that the community services provider is no longer part of NHS Norfolk but is a separate organisation with its own Chairman, Board, Chief Executive and management team. NCH&C has been operating a shadow board governance structure for some time.

2.2 As an independent NHS Trust, Norfolk Community Health and Care will be working towards achieving Foundation Trust status by 2013-14.

3. Purpose of today’s meeting

3.1 The local NHS is required to consult this Committee about substantial variation to services for patients. At this stage the change in NCH&C is an organisational change, not a substantial variation to service. Nevertheless, it is a significant organisational change in the local healthcare system and will therefore be of interest to this Committee.

3.2 Members will be aware that good quality, efficient community services are vital to the smooth running of the whole healthcare system in the County. The acute hospitals, for instance, depend on being able to transfer many patients who no longer need acute care into community health services for rehabilitation. Patients also rely on the service for healthcare in their own homes.

3.3 NCH&C’s Chairman Mrs Carrie Armitage and Chief Executive Mrs Sheila Adams O’Shea and have therefore been invited to brief the Committee. Members will have the opportunity to seek assurance about the continuity of community services as NCH&C moves towards Community Foundation Trust status.

4. Suggested approach

4.1 After Mrs Armitage and Mrs Adams O’Shea’s presentation, Members may wish to explore the following areas:-

(a) Why has NCH&C chosen the Community Foundation Trust model as opposed to integration with acute hospitals in Norfolk to improve patient flow through the healthcare system?

(b) What opportunities and threats does NCH&C anticipate when the commissioning role transfers from the PCT to GP consortia?

(c) Does NCH&C have a good understanding of its relationship with this Committee as an independent NHS Trust; particularly the requirement to consult the Committee in advance of any substantial change to the services.

4. Action

4.1 Individual Members of this Committee act as formal links with each of the NHS Trusts in Norfolk. The main duty is to attend the Trust’s public Board meetings, as a member of the audience, and to bring to the Committee’s attention any information of which it should be aware. Current link Members are:-

Mr Wright – NHS Norfolk Mr Sandell and Mr Wright – The Queen Elizabeth Hospital, King’s Lynn NHS Trust Mr J Bracey – Norfolk and Waveney Mental Health NHS Foundation Trust Mrs S Weymouth – NHS Great Yarmouth and Waveney Dr N Legg – Norfolk and Norwich University Hospital NHS Foundation Trust Mr M Carttiss and Mrs S Weymouth – James Paget University Hospital NHS Foundation Trust.

4.2 The Committee is invited to nominate a formal link Member to attend NCH&C’s public Board meetings.

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Norfolk Health Overview and Scrutiny Committee 25 November 2010 Item no 11

Norfolk Health Overview and Scrutiny Committee

ACTION REQUIRED Members are asked to suggest issues for the forward work programme that they would like to bring to the committee’s attention. Members are also asked to consider the current forward work programme:-  whether there are topics to be added or deleted, postponed or brought forward;  to agree the briefings, scrutiny topics and dates below.

Proposed Forward Work Programme 2011

Meeting Briefings/Main scrutiny topic/initial review of Administrative dates topics/follow-ups business 2011 20 Jan 2011 GP Out-of-Hours Services Commissioned by NHS Norfolk and Provided by the East of England Ambulance Service NHS Trust – report of the task and finish group.

Respite – Short Breaks for Carers – joint commissioners (NHS Norfolk and Norfolk County Council Community Services) to report on progress with developing carers’ services – including information on cross county border arrangements for respite.

Intermediate Care Implementation Monitoring Group - progress report.

3 Mar 2011 Diabetes – Children’s Services and Foot and Eye Screening Services – a progress report on implementation of the agreed recommendations from NHOSC’s October 2009 report. (Norfolk LINk is monitoring the implementation of the recommendations to the NHS. LINk to brief the Chairman on progress in December 2010).

Norfolk and Waveney Mental Health NHS Foundation Trust – proposals for changes to dementia services (county-wide).

Formation of GP Commissioning Consortia in Norfolk – reports from NHS Norfolk and NHS Great Yarmouth and Waveney on progress in establishing the GP Consortia commissioning arrangements that will succeed them from April 2013.

Changes to NHS Provided Respite Services for Adults with Learning Difficulties – consultation by the joint commissioners, Adult Social Services and NHS Norfolk, regarding changes to the respite services currently provided at 3 Mill Close, Aylsham and 3 Park View, King’s Lynn.

Autism – Children’s Services – a report from NHS Norfolk and Children’s Services on the services commissioned for children with autism in NHS Norfolk’s area.

Continuing Healthcare - consultation by NHS Norfolk Provisional date and NHS Great Yarmouth & Waveney on changes to – to be agreed local continuing health care policy (this consultation was with NHS suspended in March 2010). Norfolk and NHS Great Yarmouth and Waveney

14 April 2011 Integration of Service Delivery (Integrated Care Pilot) – report of the joint task and finish group with Community Services Overview and Scrutiny Panel.

NOTE: These items are provisional only. The OSC reserves the right to reschedule this draft timetable.

Provisional dates for update / briefing reports to the Committee 2011

October 2011 – Services for Adults with Autism – an update from NHS Norfolk, Community Services and the Learning Difficulties service on progress with commissioning services for adults with autism in line with national guidance on implementation of the Autism Strategy.

Scrutiny being done by working groups of NHOSC

 Intermediate Care – implementation monitoring group – due to bring a progress report to NHOSC on 20 January 2011 Membership:- Cllrs Nigel Legg (Chairman), John Bracey, David Bradford, David Harrison, Shirley Weymouth (Vice Chairman) & Tony Cowles (Norfolk LINK)

 GP Out-of-Hours Services – commissioned by NHS Norfolk and delivered by the East of England Ambulance Service NHS Trust – next meeting arranged for 1 December 2010. Due to report findings to NHOSC on 20 January 2011. Membership:- Cllrs Nigel Legg (Chairman), Michael Chenery of Horsbrugh, Steven Dorrington, David Harrison (Vice Chairman), Shirley Weymouth & Graham Dunhill (Norfolk LINk)

 Integration of Service Delivery (Integrated Care Pilot) – joint task and finish group with Community Services Overview and Scrutiny Panel. To report to NHOSC and Community Services OSP (NHOSC on 14 April 2011). Membership:- NHOSC - Cllrs Michael Chenery of Horsbrugh, Barbara McGoun & Shirley Weymouth. Community Services OSP – Cllrs Marion Chapman-Allen, Diana Irving & Stephen Little. Norfolk LINk – Terry Allen - co-opted (non voting) member.

NHOSC Members on Regional Joint Scrutiny Committees (task & finish basis)

Joint Committee (task & NHOSC Membership Progress finish) Neonatal Services – Cambs, Cllr David Harrison Members attended an informal Norfolk, Suffolk & Cllr Garry Sandell meeting with the Gateway Peterborough Cllr Michael Chenery of review team (i.e. NHS peer Horsbrugh review prior to publication of the proposals) on 3 November 2010. The Specialised Commissioning Group (SCG) has more work to do before deciding whether to go to public consultation. The Joint Committee will be formally established if the SCG launches a formal consultation.

Paediatric Cancer Services (0 Cllr Tony Wright The Specialised – 16 age group), Eastern Commissioning Group reported Region to the East of England Health Scrutiny Chairs Forum on 12 November 2010 that as there is only one realistic way forward for this service in the region, it now considers that formal consultation is not required. The Chairs Forum agreed that these proposals need not be subject of a formal consultation and that no JOSC need be set up.

Paediatric Cancer Services Cllr Tony Wright Likely to start in April 2011 (17 – 24 age group), Eastern Region

NHOSC Members co-opted to Norfolk LINk Working Groups

 Older People’s Health and Social Care – Shirley Weymouth

 James Paget Hospital – Acute Services – Shirley Weymouth

 Adult Mental Health – Michael Chenery of Horsbrugh

NHOSC Members appointed to NHS/CQC reference groups

 Norfolk & Suffolk mental health trusts proposed merger – reference group – Michael Chenery of Horsbrugh appointed 14 October 2010.

 Care Quality Commission – sounding board – Steven Dorrington

 Norfolk and Waveney Mental Health NHS Foundation Trust – Design and Reference Group for the new Dementia Intensive Care Unit at the Julian Hospital, Norwich – Steven Dorrington (sub John Bracey) appointed 15 October 2009